Monday, October 24, 2016

Jakarta, Indonesia

I was fortunate to travel to Jakarta, Indonesia for my
international rotation.To give some
background on the region: the city of Jakarta contains over 10 million
inhabitants, which is larger than any US city.The entire metropolitan area is estimated to contain more than 30 million
people, making it one of the largest cities in the world, second only to Tokyo,
Japan.The country, itself, is likewise
impressive: it is made up of over 13,000 islands of varying sizes located both
north and south of the equator. Indonesia spans over 3000 miles in its
east-west direction, more expansive than the contiguous United States.It is the 7th largest country in
the world in terms of combined sea and land area.I was surprised by the scale of Indonesia as
it is a country that I knew little about and do not hear mentioned much in
global news and events.I was most
impressed with the ethnic diversity of Indonesia: many of the islands have
their own separate races, cultures, languages, customs, religions due to
developing in relative isolation prior to Dutch colonization.The Republic of Indonesia was established
after liberation from Japanese occupation by the Allies after World War II.

The front entrance of RSCM, the final tertiary
referral
center for Jakarta.

My faculty hosts for the rotation were Dr. Aryadi and Dr.
Ugok, two pediatric orthopedic surgeons who are friends of our Dr. Dobbs, who
has spoken there a number of times.I
rotated mainly at RSCM hospital, which is the largest and highest-ranking referral
center in Indonesia.Most of the cases
seen at this hospital were referred from other centers due to complexity or
because they had already treated and had a complication, so in many ways this
was analogous to Barnes-Jewish Hospital.My other hosts for the trip were the wonderful residents who I
interacted with.The residents assigned
to the pediatrics rotation during my time were Dr. Adrian (5th
year), Dr. Juno (4th year), Drs. Aji and Rizqi (3rd
years) and various “Orthopedic Basics” (or interns), who seemed to help in
casting clinics and ORs on a rotating basis, thus they were different each
day.The hierarchy of academic medicine
is even more pronounced in Jakarta than what we are used to in the US system:
no request from an attending is taken lightly or deemed too arduous.The third year residents, at the attendings’
request, served as my personal liaisons to the city and hospital: picking me up
from the airport in the middle of the night, taking me to the grocery store,
often taking me to the hospital and restaurants and anywhere else I needed to
go around the city, regardless of their personal schedules and
responsibilities.At times, I felt like
a burden to them because I can’t imagine constantly taking care of a visitor along
with my responsibilities as a resident, however I came to realize that that
level of service is part of their culture, and they looked at it as an honor to
have me there as their guest.

The Children’s hospital on the RSCM complex.
This beautiful building had been built for
years,
but was still unused due to lack of funds to be able to
furnish with
appropriate equipment.

Our day-to-day schedule was actually fairly slow-moving, and
this is a result of the low operative volume.There are many systemic, bureaucratic, and economic reasons for this, but
Dr. Aryadi is only allowed one OR room per week (Wednesdays) at RSCM.Because of this, Dr. Aryadi also works at a
private hospital where he has private clinics and ORs to fill his time.There are only 900 orthopedists in a country
of about 255 millions.Only 10 are pediatric-trained,
and only 7 of these are very active.General orthopedists typically try to deal with pediatric problems on
the local level as much as possible, and refer to RSCM only when necessary.I was able to accompany Dr. Aryadi to his
private clinic (RSCM Kencana or “gold”), and found that his patient encounters
there were very similar to those I have seen at our hospitals here in terms of
acuity, timing, patient interactions, and resources.The public clinic, however, had many
eye-opening differences from what I was accustomed to.Clinic volume was high, and there was a
high-yield of operative cases seen, but most are put on the waiting list, which
can be over a year for elective cases!Access to care is certainly one of the larger problems facing Indonesian
healthcare.There are also cultural
barriers to seeking care, as many patients are fearful of physicians, and
specifically of having metal implants in their body that are thought to be
unnatural and maybe will conduct electricity and cause harm.Due to these fears, many patients with
traumatic injuries will visit “bone-setters” who will massage fractures and place
in a cast made from gauze dipped in an egg/honey mixture.This is probably adequate for fractures that
don’t need internal fixation, but they have limited knowledge of medicine and
complications, so many of these injuries are mistreated and neurovascular
complications are created or go unrecognized until too late.

Interesting Differences in Hospital Care

Outpatient clinics were conducted in the generic “surgical”
clinic that has 3 exam rooms.Pediatric
orthopedics only had one of the rooms twice per week, but we move the patients
quickly!Patients come from far and
wide, sometimes traveling for days to make their appointment.By the time we showed up to clinic, the
waiting room was already full.They were
seen on a first-come, first-serve basis.The patient, family, me, and generally all of the residents would be in
the small room together.Patients carry
all their films around with them.We
would generally look at films, examine the patient, then quickly come up with a
plan and tell the family what we would do.These problems generally were not subtle, so there was not much time
spent outlining their symptoms with a history. I don’t believe I ever saw a
patient ask a question or challenge our plan of care as is commonplace in the
US.Generally speaking, they were just
so grateful to see a doctor they accept a very paternalistic medical model.

National healthcare means that all patients can get
healthcare sponsored by the government, but it is not near the standard we are
used to.You have waiting lists for
everything.Furthermore, the government
insurance must approve studies and surgeries, including implants, and they generally
will not pay for advanced implants beyond uni-planar external fixators and
simple plates for trauma.

The hospital itself was fairly modern, albeit very
different. It has some air-conditioned spaces, usually department offices,
otherwise the hospital and wards are ambient temperature, which is generally
90-100ºF. Outdoor corridors link different parts of the hospital and separate
buildings.Jakarta is in the tropics
(just south of the equator), thus it is always hot and humid, but it varies
whether rainy or dry season.The
physicians generally all wear short-sleeved shirts and white coats.Many of the residents wore tennis shoes.The hospital has only 2 rooms for adult
orthopedic patients: 6 male patients in one room, 6 female patients in the
other.Patients are often admitted a few
days prior to their surgery to complete the workup and because they usually traveled from afar.The surgeons cannot
perform elective surgeries requiring an inpatient stay if their census is
full.In cases where they are at
capacity, the consultant surgeons will have to get together and vote on which
patients get to stay and get their treatment (Like SURVIVOR, RSCM edition).

The residents train for 6 years of medical school, which
starts post-high school.Residency is 5
years long.They qualify for residency
based off a written exam demonstrating aptitude for Orthopedic surgery, as well
as interviews, similar to our application process.There are about 16 residents per year,
meaning about 80 residents total!That
said, there were only 10 “consultants” or attendings at RSCM, and many have
appointments at private hospitals where the residents do not rotate, so there
is significantly less clinical volume than what we see in our training at
Washington University.When they are
on-call overnight, they typically see 2-3 consults per night.However, they must do everything for the patients, be it perform blood draws, position
for Xrays, various admission paperwork.If the patient needs surgery, the resident must fill out the insurance
application for surgery as well as track down the implants that would be necessary
and take them to processing to be sterilized.They do not have “standard trays” for cases and each case I saw had
individual implants that we looked at the day before and then was subsequently
peel-packed. If you did not think about a certain instrument or implant prior
to the operating room, it will not be available for you.Don’t drop things either!

In the operating theatre with the Pediatrics Residents
after
placing a post-op splint.

After walking outside to get to the separate Operating
Theatre building (or OT, as they call it), I trade my ID badge for a set of
scrubs and a key.In the locker room, I
was instructed to remove my shoes AND SOCKS and put on the community shoes,
which were different varieties of rubber crocs that probably were not
washed.Surgical mask goes up even in
hallways outside ORs, cannot take down until out of the corridors.No phones allowed (theoretically, but every
resident smuggled theirs in and taught me to do the same).Gowns were cloth and reusable, so had to wear
a plastic, impermeable butcher’s apron below gown to keep dry.If feet get bloody during case, then wash
your feet in the shower as soon as you leave OR and change crocs.Prep, drape, and timeout are pretty
consistent to our norms, but prior to incision they also pray for health of
patient.One of the surgeons, (usually
the resident who will be primary surgeon), says a prayer and everyone is silent
for a few seconds.

On Friday, they have an academic day.The morning is about 4 hours of case
presentations/conference where every case from each service is discussed with a
few consultants present to add commentary or ask questions.There usually were only a handful of cases to
discuss from each service for the week, including overnight call cases (most
trauma is handled in the regional/non-referral centers).Because of the low-volume, there was a
significant focus on in-depth presentations and full discussions so each
resident present could hopefully learn something even if they were not present
in the cases.They take huge numbers of
clinical photos for each case in order to have a good presentation for this
conference, they mentioned the goal is to have each case to have pictures such
that it could be published as a case-report, if desired.After conference, they have residency-wide
prayer for the muslim residents.Hindus
and Christians are typically then done for the day.

Interesting Cases

Case 1: High left hip dislocation in DDH.Countless children were seen with chronic
dislocations.They would still need to
wait on the ~1year surgery waiting list.

Case 1

Case 2:

Forearm
nonunion.Common problem due to cultural
barriers and access to care.

Case 2

Interesting Experiences Outside Hospital

My host residents enjoyed taking me out to eat for some traditional
Indonesian Cuisine.Some highlights (and
lowlights) included Rendang, which is traditional Sumatran way of
preparing/cooking beef, which involves a BBQ-like braise and slow-cooking.This was delicious, but a little spicy.Some items that I tried but did not enjoy as
much were fried chicken feet and cow cartilage.The majority of meals (including breakfast) were slight variations upon
the staple foods of fried rice, chicken, fish, and few vegetables.

The traffic in Jakarta is stifling, due to the population
density and congestion.Many people ride
motorbikes to weave in and out of traffic to speed up their commute, and this
leads to many patients in orthopedic clinics.There are many helpful citizens posing as “police” who will (for a small
fee) stop traffic to help you cross the street, make a turn in traffic, or park
amidst the chaos of typical.When the
real police show up, these guys go running.

Two of the residents were kind enough to invite me to play
basketball at their weekly game with other surgery residents on Friday night
around 10pm.Basketball is 2nd
most popular sport to watch/play second to football (soccer).

On Saturday morning we went to soccer
practice with the department.They have
a large (>22 player) soccer team made of only orthopedic surgery
residents.They have official jerseys,
equipment, and even a paid coach from a local gym/athletic center. The sports
practices are mandatory for interns, with the goal of building muscle and camaraderie on Saturday mornings.If you
miss practice, it is analogous to not showing up to the hospital on a workday,
and you will receive extra call shifts. We did drills for about an hour, then
played a full 11-on-11 soccer scrimmage.The interns are responsible for providing the equipment and jerseys,
making sure it is all laundered.

Summary of Experience/Overall Impressions

Visiting Indonesia was a great experience, and one that I am
very grateful for.Due to cultural and
economic influences, I encountered many problems and challenges that are unique
to the region that I had not previous seen in my training.Often, their resources to deal with these
problems were limited, and treatment approaches differed accordingly.Despite these differences, I saw that the
surgeons discussed problems, biology, and treatment principles in ways similar
to our surgeons at Washington University, and they were always trying to do the
best they could for their patients.I
found Indonesian culture to be charming and interesting, and the people
themselves were beyond hospitable and kind.I have left my international trip with many great memories, knowledge of
some new and rare problems, gratitude for the seemingly limitless resources
that we enjoy at our institutions, and most-of-all, an appreciation of the
common mission that we all share as orthopedic surgeons.

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Washington University Orthopaedic Surgery: Resident Travel Blog

Through the mentorship of faculty, our orthopaedic surgery residency program offers a resident trainee the opportunity to design a personalized international experience and participate in the practice of global medicine.